Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yoga’s effectiveness in underserved patients with more severe functional disability and pain.
One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups.
Low back pain is the leading cause of disability globally (1). Total annual back pain–related costs in the United States exceed $200 billion (2). Chronic low back pain (cLBP) affects approximately 10% of U.S. adults (3), but overall patient satisfaction with cLBP treatment is low (4). The impact of cLBP is greater in racial or ethnic minorities and in people of lower socioeconomic status (SES) (5). Physical therapy (PT), comprising individually tailored stretching and strengthening exercises, is the most common evidence-based, reimbursable, and nonpharmacologic physician referral for cLBP (6, 7). Clinical guidelines (8, 9), meta-analyses (10), and several large randomized controlled trials (11–13) also support yoga, a practice including physical poses, breathing exercises, and meditation, as an effective cLBP treatment.
Methods
Design Overview
Setting and Participants
Randomization and Interventions
Outcomes and Follow-up
Statistical Analysis
Role of the Funding Source
Results
Study Population
On average, participants reported moderate to severe functional impairment and pain. More than two thirds used analgesics for back pain. Baseline mean between-group differences were present for RMDQ, sex, and body mass index (P = 0.032, 0.088, and 0.099, respectively). However, only baseline RMDQ was identified as a confounder for the RMDQ analyses.
Adherence to Interventions and Loss to Follow-up
Primary Outcomes
Decreased pain for yoga (mean within-group change, −1.7 [CI, −2.1 to −1.4]) was noninferior to that for PT (mean within-group change, −2.3 [CI, −2.7 to −1.9]). The mean difference in pain between yoga and PT was 0.51 (1-sided CI, −∞ to 0.97). Noninferiority plots for primary outcomes are shown in Figure 3 of Supplement 2. Analyses using the last observation carried forward to account for missing data yielded similar results (Table 7 of Supplement 2).
Primary outcomes from baseline to 52 weeks.
The study was divided into a treatment phase (baseline to 12 wk) and maintenance phase (12 to 52 wk). Intention-to-treat analyses are shown. Plotted values in the treatment phase derive from models using multiple imputation to handle missing data. Values in the maintenance phase derive from longitudinal models using all available data. 95% CIs are shown. Data points are slightly offset from each other to aid interpretation. RMDQ = Roland Morris Disability Questionnaire.Top.Mean RMDQ scores adjusted for baseline scores and anchored at the study population mean at baseline.Bottom.Mean unadjusted back pain scores.
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